The following is reprinted from Metabolic Toxemia of Late Pregnancy, by Thomas H. Brewer, M.D., 1966 & 1982.

"Obesity" (page 69)

Obesity is often thought of as being a form of "malnutrition," and in a certain sense it is. However, it is necessary for
the clinician to recognize that an obese woman may be perfectly well nourished from the point of view of her taking in all
the necessary elements of nutrition. She may get fat from eating too much of a biologically adequate diet. I had occasion
to make a house call to see a young child with middle-ear infection during my general practice days. His mother, a very obese
woman of short stature (weight 195 lbs, height 4 ft, 10 in), related to me her prenatal experiences. She had delivered three
infants, and during each pregnancy she maintained her marked obesity; her obstetrician was apprehensive about her developing
toxemia with each, but she had no trouble at all with any of her pregnancies. "How did you eat during your pregnancies?"
I asked her.

"Oh, I ate like a horse; I especially like meat and milk." This woman's husband is a civil engineer with a good position
and salary, and she was "kitchen oriented," that is, she delighted in preparing good food and enjoyed eating it.

On the other side of the coin we know that many obese women are very poorly nourished because they eat too much carbohydrate
and fat and very little protein. I helped care for a young woman who ate like this and died of eclampsia. It is not possible
to distinguish from casual observation the adequately nourished obese woman from the poorly nourished one, and therefore it
is necessary to take a careful dietary history and do certain lab studies to clarify the situation. Studies done on obese
women in private practice in this nation have shown that obesity, per se, does not predispose a woman to developing
serious maternal complications, while studies done on obese women in the lower socioeconomic classes have revealed an increased
incidence of such complications.

In the management of the obese pregnant woman, physicians often make one serious mistake: they restrict dietary intake so
much that protein deficiency develops. I have observed this phenomenon in ten women who thus developed "iatrogenic" [doctor-caused]
metabolic toxemia of late pregnancy. (Controlled experimental studies done on lower primates will reveal the same phenomenon.)
One of the most striking cases occurred in a woman twenty-eight years of age having her first pregnancy. I saw her first two
days after her admission to the obstetrical prenatal ward of a university hospital. She had been referred into the hospital
by her private physician, who had been looking after her since the first trimester. She was twenty-eight weeks gestation on
admission. She was a college graduate, an intelligent and cooperative woman. On admission she had hypertension, preteinuria,
generalized edema and was having symptoms of MTLP. She had been placed on a low salt diet and a saluretic diuretic, sedation,
bed rest and the other "routine therapy" for "toxemia of pregnancy." A very poor history was on her chart.

As I elicited a fairly detailed history, it became obvious what her problem was and how it had developed. Early in pregnancy
she was somewhat overweight, being 5 feet, 7 inches tall and weighing about 175 lbs. Her physician placed her on a starvation
diet of 400 cal and strengthened her will to fight her good appetite with amphetamines. She faithfully followed this diet,
but in spite of it, as pregnancy advanced into the latter half she continued to gain weight. Six weeks prior to admission,
she developed clinical edema so the physician placed her on oral saluric diuretics and advised salt restriction and continued
her on the 400-cal diet. She followed this regimen faithfully also but continued to develop progressively severe signs and
symptoms of MTLP, including proteinuria. Her physician then referred her into the university hospital for more expert care.

It is obvious that the obstetrical resident's initial plan of therapy was unscientific because of his failure to take an adequate
history and to find out as much as possible about the events which preceded the patient's admission to the hospital. The diuretic
was stopped. A serum sodium revealed a concentration of 118 me/liter; a total serum protein was 5.4gm% with albumin of 1.80gm%
(by electrophoresis). The patient was given sodium and taken off the low sodium diet. After ten days during which she showed
slight improvement, she went into labor spontaneously and delivered a 2100 gm premature infant which suffered the respiratory
distress syndrome but survived. (It is of interest to note that the total serum proteins on the infant's cord blood were only
4.8gm%, and it was given some intravenous human serum albumin.)

On the day of the patient's discharge from the hospital I talked with her husband to verify her history. He was quite perplexed
as he told me: "I just don't understand it; she followed the doctor's orders to the letter. She starved herself throughout
this pregnancy eating less in a day than she used to eat in one meal, and yet she continued to gain weight and got sick."

It is perfectly safe for obese women to diet during pregnancy provided they have an adequate intake of protein and of all
the essential elements of good nutrition. However, it is much more important for the obese woman to eat a good adequate diet
than it is for her to lose weight during pregnancy. It is necessary for the physician and his patient to place the primary
interest on good nutrition, since the obese woman may have poor dietary habits; weight reduction must be looked on as a secondary
and less important goal.

Note from Joy: As you evaluate your nutrition and lifestyle, it would also be helpful to evaluate your level of activity
and add extra nutritious calories if you use extra calories during the week, with jogging, biking, skating, skiing, or other
sports, or other extra calorie-depleting activities, like teaching, dancing, waitressing, nursing, doctoring, or other activities
that keep you on your feet all day. Caring for other children, working both outside and in the home, caring for other family
members, and housework would also use up a lot of calories, especially as the baby gets bigger and you burn up calories just
carrying around the extra weight of the baby, uterus and extra blood volume. You can also evaluate whether other stresses
in your life might be using up extra calories. If you have had extra stresses in your life, then adding extra nutritious
calories and other nutrients to compensate for those calorie-burning stresses would help to keep your blood volume expanded
and your pregnancy and baby healthy.

The usual eating pattern that we suggest that pregnant women can use to keep up with their nutritional needs is as follows:
breakfast, mid-morning snack, lunch, mid-afternoon snack, supper, bedtime snack, middle-of-the-night snack. If you are having
trouble keeping up with the amount of food that you need, or if you are having trouble keeping your blood pressure within
a normal range, we suggest that you eat something with protein in it (glass of milk, cheese cubes, handful of nuts, handful
of trail mix, etc), every hour that you are awake.

If you are dealing with nausea, vomiting, or diarrhea, it is important to try to alleviate those problems as soon as possible,
since they also contribute to depleting your blood volume. You can try frequent, small snacks, herbs, and homeopathy to help
you in this effort. If you decide to try using ginger, which can be very effective for "morning" sickness, use it only in
small amounts, and only just before eating some kind of food, since too much ginger can cause bleeding and possibly miscarriage.

It would also be helpful for you to evaluate whether you are ever in situations that result in your losing extra sweat and
salt--situations such as gardening in hot weather, exercising, living in hot homes during the winter, or living without air-conditioning
in the summer, or working in over-heated working conditions. If you do have one of those situations, it would be helpful
for you to add extra salt and nutritious fluids to your daily nutrition. This extra effort will help to keep your blood volume
expanded to where it needs to be to prevent elevated blood pressure, pre-eclampsia, and other complications.

Eating the recommended amount of protein every day isn't enough to keep your blood volume expanded to where it needs to
be for preventing complications in pregnancy. It is also vitally important to make sure that your intake of nutritious calories
and salt are also at the recommended levels, with special extra allowances added as needed for your unique situation.

I would also like to add here the assurance that Dr. Brewer is not blaming the mother for her situation. He is clearly blaming
her doctor for not having the routine of examining her nutritional status and doing a differential diagnosis for her. He
is saying that if her doctor is not doing this with her, then it is most important for her to do it for herself, for the sake
of her own health and that of her baby.

While the use of amphetamines and diuretics may no longer be considered the mainstream treatment of choice for the symptoms
of toxemia, other methods of weight control in pregnancy and treatments for toxemia are currently in vogue which are equally
hazardous to both the baby and the mother. And unfortunately, the hazards of these current treatments are no more recognized
by the mainstream practitioners of today than were the hazards of the earlier use of amphetamines and diuretics by the practitioners
of yesterday. I have been witness to some of the current hazardous treatments, just within the past 5-10 years.

I worked for a homebirth midwifery practice for several years. For most of that time, all the midwives were supportive of
the use of the Brewer Diet by the clients of the practice. The last year of my time there, we got a new midwife on staff
who was very opposed to the use of the Brewer Diet. Whenever we got a new client who was the least little bit on the plump
side, she would apparently tell her to get a little more exercise and eat a little less carbohydrates. When her blood pressure
would start to creep up, she would tell her to cut back on her salt a little bit. No amount of my trying to explain the Brewer
insights to her made any headway. As a result, within the first six months of her being on staff, we had 2-3 clients who
had to be hospitalized with blood pressure problems and premature labor, as I recall, which was very uncharacteristic of our
practice.

So it is very important that we not dismiss the historical accounts that Brewer has documented for us. We need not look down
our noses at his reports of the starvation-amphetamine-diuretic practices of the physicians around him in his early days,
and his efforts to stop those practices. We have our own faulty treatments in our own time, which are based on the same faulty
thinking, and are just as hazardous as the treatments that he witnessed.

In addition, unfortunately, some areas of the "alternative medicine" community have apparently followed mainstream medicine
in the belief that diuretics are important and useful for treating edema and elevated blood pressure in pregnancy. Many pregnancy
teas and some supplements and juices include nettle, dandelion, alfalfa, bilberry, or celery, all of which have diuretic properties.
Diuretics are no safer for pregnancy in herbal form than they are in prescription medications, so it is important for pregnant
women to watch which herbs they are taking.